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Virtual In-Service Registration
Please complete the information below to reserve your spot for the Virtual In-Service training, hosted by Triage Cancer & Cancer and Careers.
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1.
First Name
(Required.)
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2.
Last Name
(Required.)
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3.
Email Address
(Required.)
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4.
Phone
(Required.)
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5.
Street Address
(Required.)
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6.
City
(Required.)
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7.
State
(Required.)
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8.
Zip Code
(Required.)
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9.
Company/Organization (if applicable)
(Required.)
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10.
Title (if applicable)
(Required.)
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11.
How did you hear about this in-service program?
(Required.)
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12.
What type of cancer do your patients have?
(Required.)
13.
Are you planning on requesting free continuing education credits?
Yes, from the American Nurses Credentialing Center's Commission on Accreditation
Yes, from the National Association of Social Workers
Yes, from the New York State Education Department State Board for Social Work
Yes, from the State California Board of Registered Nursing
Yes, a general certificate of attendance
N/A
14.
License number required for CEUs: (If you are not requesting CEUs, please write "N/A)
15.
What age range applies to you?
0-18
19-39
40-64
65+
Prefer not to share
16.
I identify my race/ethnicity as
Native American
Asian or Pacific Islander
Black or African American
Hispanic or Latinx
Middle Eastern or North African
White
Prefer not to answer
Other (please specify)
17.
What gender do you most identify with?
Woman
Man
Transgender
Non-binary/non-conforming
A gender not listed here
Prefer not to answer
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18.
Do you need an accommodation?
(Required.)
Yes
No
19.
If you need an accommodation, please describe:
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